Gestational weight gain in twin pregnancies in Korea: application of the 2009 Institute of Medicine recommendations

Objective@#To investigate the effect of gestational weight gain (GWG) on maternal and neonatal outcomes based on the Institute of Medicine (IOM) guidelines for twin pregnancies. @*Methods@#This study included women with twin pregnancies who delivered at Seoul National University Bundang Hospital. Based on the weight gain per gestational week according to the 2009 IOM guidelines, the subjects were divided into the following 3 groups: inadequate, adequate, and excessive GWG. We compared the maternal and neonatal outcomes of each group. @*Results@#A total of 1,738 twin pregnancies were included in our study. Of these cases, 881, 694, and 163 (50.7%, 39.9%, and 9.4%, respectively) twin pregnancies were categorized into the inadequate, adequate, and excessive GWG groups, respectively. In the inadequate GWG group, the risks of preterm birth <34 weeks (aOR, 2.33, 95% confidence interval [CI], 1.63–3.34) and delivering neonates who were small for gestational age (aOR, 1.92, 95% CI, 1.42–2.60) were increased, and the risk of preeclampsia (aOR, 0.49, 95% CI, 0.32–0.76) was decreased. The excessive GWG group had an increased risk of the neonates being large for gestational age (aOR, 1.79, 95% CI, 1.15–2.81). @*Conclusion@#The 2009 IOM recommendations for GWG can be applied to Korean women with twin pregnancies to help achieve optimal maternal and neonatal outcomes. However, more than half of the women were categorized as having inadequate weight gain according to the guidelines. Further studies should be performed to obtain Korean national references for GWG in twin pregnancies.

Subsequent pregnancy outcomes according to the presence of acute histologic chorioamnionitis in women with spontaneous preterm delivery

OBJECTIVE: To compare subsequent pregnancy outcomes according to the presence of acute histologic chorioamnionitis (HCA) in women with spontaneous preterm delivery (SPTD).METHODS: Among 1,706 women who gave birth twice or more at our institution, 138 women delivered spontaneously at preterm (<37.0 weeks). Subsequent deliveries occurred at our institution and placental biopsy results were available. The study population was categorized into 2 groups based on the presence of acute HCA at the time of SPTD: HCA group (n=52) and non-HCA group (n=86). The primary outcome measures were gestational age at delivery, birthweight, and frequency of preterm delivery in subsequent pregnancies.RESULTS: The median gestational age at the time of SPTD was 34.0 weeks (interquartile range [IQR], 28.9–35.3 weeks), and the frequency of acute HCA was 52/138 (38%). There were no differences in gestational age at delivery, birthweight, and frequency of preterm delivery between the HCA group and non-HCA group (median gestational age at delivery, 38.0 weeks (IQR, 36.7–38.8 weeks) in the HCA group vs. 37.9 weeks (IQR, 35.7–39.0 weeks) in the non-HCA group; frequency of preterm delivery, 14/52 (27%) in the HCA group vs. 33/86 (38%) in the non-HCA group; and median birthweight, 3.14 kg (IQR, 2.64–3.45 kg) in the HCA group vs. 2.95 kg (IQR, 2.44–3.36 kg) in the non-HCA group; P>0.1 for all.CONCLUSION: The presence of acute HCA in women at prior SPTD did not significantly affect their subsequent pregnancy outcomes.

Gestational weight gain in twin pregnancies in Korea: application of the 2009 Institute of Medicine recommendations

Objective@#To investigate the effect of gestational weight gain (GWG) on maternal and neonatal outcomes based on the Institute of Medicine (IOM) guidelines for twin pregnancies. @*Methods@#This study included women with twin pregnancies who delivered at Seoul National University Bundang Hospital. Based on the weight gain per gestational week according to the 2009 IOM guidelines, the subjects were divided into the following 3 groups: inadequate, adequate, and excessive GWG. We compared the maternal and neonatal outcomes of each group. @*Results@#A total of 1,738 twin pregnancies were included in our study. Of these cases, 881, 694, and 163 (50.7%, 39.9%, and 9.4%, respectively) twin pregnancies were categorized into the inadequate, adequate, and excessive GWG groups, respectively. In the inadequate GWG group, the risks of preterm birth <34 weeks (aOR, 2.33, 95% confidence interval [CI], 1.63–3.34) and delivering neonates who were small for gestational age (aOR, 1.92, 95% CI, 1.42–2.60) were increased, and the risk of preeclampsia (aOR, 0.49, 95% CI, 0.32–0.76) was decreased. The excessive GWG group had an increased risk of the neonates being large for gestational age (aOR, 1.79, 95% CI, 1.15–2.81). @*Conclusion@#The 2009 IOM recommendations for GWG can be applied to Korean women with twin pregnancies to help achieve optimal maternal and neonatal outcomes. However, more than half of the women were categorized as having inadequate weight gain according to the guidelines. Further studies should be performed to obtain Korean national references for GWG in twin pregnancies.

Hemodynamic Adaptations to Regular Exercise in People With Spinal Cord Injury

OBJECTIVE: To investigate the real-time cardiovascular response to the progressive overload exercise in different levels of spinal cord injury (SCI), and to find out whether regular exercise has effect on these cardiovascular responses. METHODS: The study enrolled 8 able-bodied individuals in the control group plus 15 SCI subjects who were divided into two groups by their neurological level of injury: high-level SCI group (T6 or above) and low-level SCI group (T7 or below). Also, subjects were divided into exercise group and non-exercise group by usual exercise habits. We instructed the subjects to perform exercises using arm ergometer according to the protocol and checked plethysmograph for the real time assessment of blood pressure, heart rate, and cardiac output. RESULTS: Six subjects were included in high-level SCI group (3 cervical, 3 thoracic injuries), 9 subjects in low-level SCI group (9 thoracic injuries), and 8 able-bodied individuals in control group. During arm ergometer-graded exercise, mean arterial pressure (MAP) was significantly lower in high-level SCI subjects of non-exercise group, compared with high-level SCI subjects of exercise group. In addition, HR was significantly higher in low-level SCI group compared with control group. CONCLUSION: There are significant differences in mean arterial pressure of high-level SCI group according to usual exercise habits. We discovered that even in non-athlete high-level SCI, regular exercise can bring cardiac modulation through blood pressure control.

Simple mathematical formulae for estimation of median values of fetal biometry at each gestational age

OBJECTIVE: The aim of this study was to propose simple mathematical formulae to estimate median values of fetal biometry including biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL) at each gestational age (GA) easily without looking up the previously established reference values. METHODS: Simple mathematical formulae to estimate median values of fetal biometric values at each gestational week were inferred. To validate these formulae, three different linear equations were derived from previously reported reference values of median BPD, AC and FL using regression analysis at each gestational week. Finally, calculated data through the inferred formula were compared to retrospectively collected data (observed data). RESULTS: The equation revealing the relationship between BPD and GA was: median BPD (cm)=GA (wk)/4. Using this simple mathematical formula, the absolute percentage error between observed data and calculated data ranged from 0.12% to 7.50%. The equation between AC and GA was: median AC (cm)=GA (wk)-5. Through this formula, the absolute percentage error was analyzed same as above and it ranged from 0.30% to 4.76%. Lastly the derived formula between FL and GA was: median FL (cm)=GA (wk)/5 and the absolute percentage error ranged from 4.52% to 16.75%. CONCLUSION: The three simple formulae suggested in our study showed a significantly easy way to estimate the median values of fetal biometry at each gestational week with good reliability.

Effect of Regular Exercise on Cardiopulmonary Fitness in Males With Spinal Cord Injury

OBJECTIVE: To evaluate the cardiopulmonary endurance of subjects with spinal cord injury by measuring the maximal oxygen consumption with varying degrees of spinal cord injury level, age, and regular exercise. METHODS: We instructed the subjects to perform exercises using arm ergometer on healthy adults at 20 years of age or older with spinal cord injury, and their maximal oxygen consumption (VO2max) was measured with a metabolic measurement system. The exercise proceeded stepwise according to the exercise protocol and was stopped when the subject was exhausted or when VO2 reached an equilibriu RESULTS: Among the 40 subjects, there were 10 subjects with cervical cord injury, 27 with thoracic cord injury, and 3 with lumbar cord injury. Twenty-five subjects who were exercised regularly showed statistically higher results of VO2max than those who did not exercise regularly. Subjects with cervical injury showed statistically lower VO2max than the subjects with thoracic or lumbar injury out of the 40 subjects with neurologic injury. In addition, higher age showed a statistically lower VO2max. Lastly, the regularly exercising paraplegic group showed higher VO2max than the non-exercising paraplegic group. CONCLUSION: There are differences in VO2max of subjects with spinal cord injury according to the degree of neurologic injury, age, and whether the subject participates in regular exercise. We found that regular exercise increased the VO2max in individuals with spinal cord injury.

Pain-Related Evoked Potential in Healthy Adults

OBJECTIVE: To investigate the normal data of pain-related evoked potentials (PREP) elicited with a concentric surface electrode among normal, healthy adults and the relationship between PREP and pain intensity. METHODS: Sixty healthy volunteers (22 men and 38 women; aged 36.4+/-10.7 years; height, 165.4+/-7.8 cm) were enrolled. Routine nerve conduction study (NCS) was done to measure PREP following electrical stimulation of hands (C7 dermatome) and feet (L5 dermatome). Negative peak (N), positive peak (P) latencies, peak to peak (NP) amplitudes, conduction velocity (CV), and verbal rating scale (VRS) score were obtained. Linear regression analysis tested for significant relevance between variables of PREP and VRS score. RESULTS: Normal NCS results were obtained in all subjects. N latency of hand PREP was 163.8 +/-40.0 ms (right) and 161.0+/-39.9 ms (left). N latency of foot PREP was 178.0+/-43.9 ms (right), 180.4+/-43.4 ms (left). NP amplitude of hands was 20.6+/-10.6 microV (right) and 21.9+/-11.6 microV (left). NP amplitude of feet was 18.8+/-8.3 microV (right) and 19.0+/-8.4 microV (left). The calculated CV was 13.2+/-4.7 m/s and VRS score was 3.8+/-1.0. A highly significant positive correlation was evident between VRS score and NP amplitude (y=0.1069x+1.781, r=0.877, n=60, p<0.0001). CONCLUSION: PREP among normal, healthy adults revealed a statistically significant correlation between PREP amplitude and VRS score.

Intra-Amniotic Infection/Inflammation as a Risk Factor for Subsequent Ruptured Membranes after Clinically Indicated Amniocentesis in Preterm Labor

The aim of this study was to determine whether intra-amniotic infection/inflammation (IAI) was associated with subsequent ruptured membranes in women with preterm labor and intact membranes who had a clinically indicated amniocentesis. This retrospective cohort study included 237 consecutive women with preterm labor (20-34.6 weeks) who underwent amniocentesis. The clinical and laboratory parameters evaluated included demographic variables, gestational age, C-reactive protein (CRP) and amniotic fluid (AF) white blood cell, interleukin-6 (IL-6) and culture results. IAI was defined as a positive AF culture and/or an elevated AF IL-6 level (>2.6 ng/mL). The primary outcome was ruptured membranes in the absence of active labor occurring within 48 hours of amniocentesis. Preterm premature rupture of membranes subsequently developed in 10 (4.2%) women within 48 hr of amniocentesis. Multivariate analysis demonstrated that only IAI was independently associated with the ruptured membranes occurring within 48 hr of amniocentesis. In the predictive model based on variables assessed before amniocentesis, only CRP level was retained. IAI is an independent risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor. Prior to amniocentesis, measurement of serum CRP level can provide a risk assessment for the subsequent development of ruptured membranes after the procedure.

Comparison of Transcranial Magnetic Stimulation and Electroneuronography Between Bell's Palsy and Ramsay Hunt Syndrome in Their Acute Stages

OBJECTIVE: To examine the neurophysiologic status in patients with idiopathic facial nerve palsy (Bell's palsy) and Ramsay Hunt syndrome (herpes zoster oticus) within 7 days from onset of symptoms, by comparing the amplitude of compound muscle action potentials (CMAP) of facial muscles in electroneuronography (ENoG) and transcranial magnetic stimulation (TMS). METHODS: The facial nerve conduction study using ENoG and TMS was performed in 42 patients with Bell's palsy and 14 patients with Ramsay Hunt syndrome within 7 days from onset of symptoms. Denervation ratio was calculated as CMAP amplitude evoked by ENoG or TMS on the affected side as percentage of the amplitudes on the healthy side. The severity of the facial palsy was graded according to House-Brackmann facial grading scale (H-B FGS). RESULTS: In all subjects, the denervation ratio in TMS (71.53+/-18.38%) was significantly greater than the denervation ratio in ENoG (41.95+/-21.59%). The difference of denervation ratio between ENoG and TMS was significantly smaller in patients with Ramsay Hunt syndrome than in patients with Bell's palsy. The denervation ratio of ENoG or TMS did not correlated significantly with the H-B FGS. CONCLUSION: In the electrophysiologic study for evaluation in patients with facial palsy within 7 days from onset of symptoms, ENoG and TMS are useful in gaining additional information about the neurophysiologic status of the facial nerve and may help to evaluate prognosis and set management plan.

Relationship between Maternal Serum C-Reactive Protein, Funisitis and Early-Onset Neonatal Sepsis

The aim of this study was to determine whether maternal serum C-reactive protein (CRP) is of value in predicting funisitis and early-onset neonatal sepsis (EONS) in women with preterm labor or preterm premature rupture of membranes (PROM). This retrospective cohort study included 306 consecutive women with preterm labor or preterm PROM who delivered preterm singleton neonates (23-35 weeks gestation) within 72 hr of CRP measurement. The CRP level was measured with a highly sensitive immunoassay. The sensitivity, specificity, positive predictive value, and negative predictive value of an elevated serum CRP level (> or = 8 mg/L) were 74.1%, 67.5%, 32.8%, and 92.4% for funisitis, and 67.7%, 63.3%, 17.2%, and 94.6% for EONS, respectively. Logistic regression analysis demonstrated that elevated levels of serum CRP were significantly associated with funisitis and EONS, even after adjusting gestational age. The maternal serum CRP level obtained up to 72 hr before delivery is an independent predictor of funisitis and EONS in women with preterm labor or preterm PROM. A low serum CRP level (< 8 mg/L) has good negative predictive value in excluding funisitis and EONS, and may therefore be used as a non-invasive adjunct to clinical judgment to identify low-risk patients.

Second trimester listeriosis followed by fetal death in utero (FDIU): A case report / 대한산부인과학회지

Listeriosis is an infectious disease caused by Listeria monocytogenes, a gram positive, facultatively anaerobic bacterium. Listeriosis occurs primarily in newborn infants, elderly patients, immunocompromised patients and pregnant women. One third of the patients are pregnant women, and complications of this disease include miscarriage, stillbirth and preterm labor. We experienced a case of listeriosis in a singleton pregnancy at 23rd week of gestation that presented with fever, chill, lower abdominal pain, backache, and eventually resulted in fetal death in utero. Autopsy results of the stillborn baby, as well as blood and amniotic fluid culture of the mother confirmed Listeria monocytogenes infection. Proper antibiotics therapy thereafter led to clear recovery of the infected mother. We report this case with a brief review of literature.

Non-invasive prediction of clinical infection in women with preterm labor / 대한산부인과학회지

OBJECTIVE: To develop a model based on non-invasive variables to predict the probability of subsequent maternal and/or neonatal clinical infection in women admitted to hospital for preterm labor with intact membranes. METHODS: Transvaginal ultrasound for measurement of cervical length was performed and maternal blood was collected for the determination of white blood cell (WBC) count at admission in 165 consecutive women with preterm labor (between 20.0 and 35.0 weeks). Clinical infection was defined as the presence of clinical chorioamnionitis at delivery or early onset neonatal sepsis. Receiver operating characteristic (ROC) curves and logistic regression analysis were used for statistical analyses. RESULTS: The prevalence of clinical infection was 5% (8/165). Women who developed clinical infection had a significantly lower median gestational age at admission, a lower shorter median cervical length, and a higher median WBC count as compared to those who did not develop clinical infection. Logistic regression analysis was performed and a final model was chosen, which included maternal blood WBC, cervical length, and gestational age as the best predictors of clinical infection. A risk score was calculated containing these 3 variables for each patient. The model was shown to have an adequate goodness of fit (P=0.202), and the area under the ROC curve was 0.822, indicating reasonably good discrimination. CONCLUSION: In women admitted to hospital for preterm labor with intact membranes, the risk for the subsequent maternal and/or neonatal clinical infection can be predicted non-invasively with a risk score based on cervical length at admission, maternal blood WBC, and gestational age.

Pregnancy outcomes of antenatally diagnosed congenital cystic adenomatoid malformation of lung / 대한산부인과학회지

OBJECTIVE: To determine the accuracy of antenatal diagnosis, pregnancy outcome and the predictors for adverse outcome in antenatally diagnosed congenital cystic adenomatoid malformation (CCAM). METHODS: A retrospective review was performed on a total of 32 patients with antenatally diagnosed CCAM between January, 1999 and June, 2008. RESULTS: Of 32 cases with antenatally diagnosed CCAM, 8 patients were lost to follow-up. In remaining 24 patients, postnatal histologic examination and/or radiologic study showed definitive diagnostic features of CCAM (n=20), pulmonary sequestration (n=3) and congenital lobar emphysema (n=1). The accuracy of antenatal diagnosis was 83.3% (20/24). The rate of presence of hydrops and/or ascites was 10% (2/20) in those with CCAM confirmed postnatally. Of the 2 patients with ascites and/or hydrops, thoraco-amniotic (TA) shunt was performed in one case with hydrops and termination was done in the other case. All of the 15 cases with ongoing pregnancy were delivered at term, except one with TA-shunt who was born at 33(+3) weeks of gestation (mean gestational age at birth+/-standard deviation; 39.6+/-2.2 weeks, mean birth weight; 3,200+/-500 gram). All 15 neonates were discharged alive without any complication. Antenatal sonographic microcystic lesion was associated with postnatal histologic type III lesion [5 type III lesions in 7 microcystitc cases (71.4%) vs. no type III lesion in 13 macrocystic cases (0%), P<0.01]. CONCLUSION: The incidence of ascites and/or hydrops was 10% (2/20) in fetuses with CCAM. Antenatally diagnosed CCAM has an excellent prognosis in the absence of signs of ascites and/or hydrops.

Discrepancy in cytogenetic results between amniotic fluid cells and other fetal tissues: A case report / 대한산부인과학회지

We present two fetuses who were prenatally diagnosed by amniocentesis as having chromosomal mosaicism but who had a normal karyotype in the fetal blood by cordocentesis. One of the both fetuses had Turner and the other had trisomy 20 mosaicism. The prognosis for Turner mosaicism and trisomy 20 mosaicism diagnosed prenatally has yet to be established. The pregnancy with 45,X/46,XX mosaicism was terminated at 23+3 weeks' gestation. Autopsy findings showed no features of Turner's syndrome. Postnatal cytogenetic analysis revealed 45,X[4]/46,XX[52] mosaicism in skin and 46,XX in the lung tissue. The other fetus had amniocytes with trisomy 20 mosaicism and fetal cord blood cells with a normal karyotype. The baby was delivered at 38+2 weeks' gestation. At birth and 3 months after birth, no apparent abnormal findings were found. These cases with chromosomal discrepancy among various fetal tissues are rare. Two cases were discussed with the review of literature.

Recurred Giant Sacral Schwannoma: Report of a Case and Review of the Literature / 대한산부인과학회잡지

Retroperitoneal Schwannomas are mostly benign encapsulated neoplasms originating from the Schwann cells of the retroperitoneal peripheral nervous systems. They are rare, but when the tumors occur, they can be large and difficult to diagnose because of a wide variety of nonspecific symptoms and findings on radiologic studies. The treatment of choice is a simple enucleation but sometimes conservative approach is inevitable. There are some discrepancies of the prognosis of conservative approach. A 54-year-old woman presented with a 4 month history of voiding difficulty and abdominal palpable mass. She had a history of partial resection of mass which was diagnosed as a retropretoneal schwannoma nine years ago. Computerized tomography revealed bilateral hydronephrosis and a increased presacral mass that destructed sacrum. Left percutaneous nephrostomy was performed preoperatively. We performed a conservative core resection and ultrasonic aspiration of the mass because of its dense adherence to major nerves and iliac vessels. After operation, percutaneous nephrostomy were removed. Voiding difficulty and left hydronephrosis were disappeared but right hydronephrosis was remained with improvement. Double J catheter was inserted to right ureter. Five months after surgery, the size of remained mass is reduced and bilateral hydronephrosis were disappeared.

A Case of a M llerian Duct Remnant Leiomyoma Suspected of Ovarian Tumor in a Woman with M llerian Dysgenesis / 대한산부인과학회잡지

In women, leiomyomas are very common diseases and may arise from any organs containing smooth muscle. However, they are extremely rare in M llerian duct remnant. A medline research disclosed only 13 published cases including 3 domestic cases. We report a case of a M llerian duct remnant leiomyoma in a woman of congenital vaginal agenesis with M llerian dysgenesis whose chief complaint was a palpable pelvic mass suspected of an ovarian tumor.